Healthcare Provider Details

I. General information

NPI: 1619730173
Provider Name (Legal Business Name): BLANCA CHARLES RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2024
Last Update Date: 02/06/2024
Certification Date: 01/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4502 E 41ST ST
TULSA OK
74135-2536
US

IV. Provider business mailing address

11479 S 264TH EAST AVE
COWETA OK
74429-6750
US

V. Phone/Fax

Practice location:
  • Phone: 918-660-3071
  • Fax:
Mailing address:
  • Phone: 918-407-4999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number98202
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number21420039
License Number StateOK
# 3
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: